Complications with tibial shaft fractures

The most common complications in tibial shaft fracture are:

• Nonunion
• Osteomyelitis
• Malalignment with malunion

Nonunion is the result of a combination of biological and/or mechanical errors that interfere with the bone healing process. In the tibial shaft, there are only muscles in the lateral side. Therefore, the vascular supply of the medial tibia is poor. This can sometimes lead to nonunion. Improper handling of the muscles and soft tissue in combination with poor surgical technique and suboptimal implant selection can lead to tibial nonunion.

Osteomyelitis can occur in the tibia in presence of an open fracture or iatrogenic contamination.

Rotational malalignment in comminuted fractures can occur due to a lack of recognizable landmarks that aid the surgeon in proper alignment of the limb. Mild loss of length or a moderate malalignment on the sagittal plane (procurvatum or recurvatum) does not affect the patient’s functional outcome, whereas malalignment on the frontal (varus or valgus) or axial plane can severely compromise limb function.

Limb alignment can be assessed by clinical evaluation and intraoperative fluoroscopy or radiographs.

The radiograph shows a pin inserted too far caudal into the stifle joint (left) / tarsal joint (right).

Lateral radiograph of a 42-B3 tibial fracture stabilized with a short 3.5mm “string of pearl” plate. Note the sagittal plane angulation.

Early post-operative failure of the repair by tibial fracture. The failure is likely the result of a combination of a short plate and the weakening effect of the most proximal screw placed through or near the caudal cortex.

When a plate is too short it can lose the biomechanical advantage of bridging the bone, and may lead to a catastrophic implant failure.

Preoperative radiographs of a 42-B2 fracture of the tibia in a 14-year-old Border Terrier.

The fracture was repaired using a 2.0/2.7 Veterinary Cuttable Plate. Although the plate was intended to work as a neutralization plate, the lack of reduction and stabilization of the short oblique fracture (arrow) make this plate a bridging plate.

Implant failure by fatigue at 3 weeks postoperative at the level of the previously highlighted short oblique fracture.

2-year-old American Shorthair cat, fell from a 3-4 floor balcony.

Radiographs of the left leg show a 42-C2 fracture.

Radiographs of the right leg show a 42-C3 fracture.

Post-operative radiographs show fracture was repaired with ESF IA on the left side. The decision was to approach this minimally invasively, although bone plating C2 fractures are recommended.

The right side was also treated minimally invasively. Note the multiple fissures that made it impossible to place implants in the midsection.

10 days post-operative radiographs show failure on both the left…

…and the right side.

At 10 days after the first surgery the cat was reoperated with 2.4 LCP MIPO on the left side. Although the external fixator type IA may have worked if this was a unilateral injury, bone plating should have been chosen initially in this patient.

The right side was also treated with 2.4 mm LCP minimally invasively.

The cat was followed-up radiographically at 2, 3 and 5-months post-operative.

Radiographs at the 5-month follow-up on left show a nonunion.

Radiographs at the 5-month follow-up on right side show a nonunion.

Radiographs 2 months after BMP show the left side healing.

Radiographs 2 months after BMP show the right side healing.